1. Bleeding in Newborns
Dr. Kalpana Malla
MD Pediatrics
Manipal Teaching Hospital
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2. Introduction
• Neonates are susceptible to bleeding for
various reasons
Immaturity of the haemostatic system
because of quantitative and qualitative
deficiency of coagulation factors
Maternal disease and drugs
Birth trauma
Other conditions - sepsis and asphyxia

3. Clinical presentation
• Bleeding in neonates may present with
Oozing from the umbilical stump
Cephalhaematoma
Bruising , Petechiae
Bleeding from peripheral venipuncture or
procedure sites
Bleeding into scalp

4. Clinical presentation
Bleeding following circumcision
Intracranial haemorrhage
Bleeding from mucous membranes
Unexplained anemia and hypotension

5. • A detailed history and examination essential
in the assessment of bleeding neonate
History includes
• Maternal diseases as ITP, preeclampsia and
diabetes
• Maternal exposure to drugs as
aspirin, anticonvulsants, rifampicin and
isoniazid
• Family history of bleeding disorders
• Previous affected siblings

6. Laboratory Evaluation
• PTT Intrinsic cascade
• PT Extrinsic cascade (II, VII, IX, X)
• Platelet count -
• Bleeding Time
• Clotting factor
• Factor Analysis
• Platelet functions

8. Etiology
• Coagulation disorders - acquired
congenital
• Platelet disorders -thrombocytopenia
function defects
• Combination of above factors – DIC
• Defects in fibrinolytic pathway
• Trauma

9. Coagulation disorders
• Transient - Vitamin K deficiency
Maternal drug use
• Congenital - Autosomal dominant- vWF
X linked recessive – VIII,IX
Autosomal recessive – II,V,VII

10. Vitamin K deficiency
• VKD factors – Required for gamma
carboxylation of II, VII, IX, and X
• Causes – breast milk has low vit K
lack of gut flora
no placental transfer

11. VKDB
• Early , Classic, and Late forms
• Early VKDB – in first day
• Severe bleeding – GI and ICH
• Cause – Maternal drug intake
Phenytoin, phenobarb,
ATT, warfarin

12. VKDB
Classical form: 2-7 days of age
• 0.25-1.7% of all babies
• Cause – not received prophylaxis
on breast feeds, sterile gut, lack of
placental transfer
Late form : 2-8 weeks of age
• Boys > girls, 5-10/1 lac
• Well , breastfed, term baby
• Liver disease
• Malabsorption

13. Management of VKDB
• Prolonged PT , APTT (if severe)
• Normal platelets and fibrinogen
• PIVKA – half life of 70 hrs
• Factor assays of vit K dependent
factors
• Treatment – 1mg iv or sc
• FFP in severe cases and PCC

14. Prophylaxis of VKDB
• Early VKDB- single IM inj of vit K at
birth and oral Vit K to mother for
last 4 weeks
• Classical and Late forms –
IM Vit K at birth
oral Vit K at 0 , 4 days and 4 weeks
In preterms – Weekly iv Vit K

15. Hemophilia in the Newborn
• Factor VIII or XI deficiency
– A good family history goes a long way

16. Hemophilia A
• Most common inherited clotting factor def
• X linked recessive, 1 in 4000 males
• 1/3rd of cases present in newborn period
• ICH(25%), cephalhematoma(10-15%)
• Post circumcision bleed is characteristic
• Family history – absent in 30%
• Inv – prolonged APTT, normal PT, normal
platelets.
• Factor VIIIc assay level <2% severe, 2-10%
moderate, >10% mild

17. Hemophilia A
• Treatment – Factor VIII concentrates
50 -100 U/kg
• Raise level to 100%
• In ICH – factor infusion for 14 days
• In doubtful cases – cryoprecipitate or FFP
• Management of antenatally detected
cases:
- Avoid difficult delivery , oral Vit K
- Cord blood bleeding tests, factor VIII
- No role for prophylactic Factor VIII

18. CNS Bleed

19. Hemophilia B
• XLR
• Deficiency of Factor IX
• Less common than the classical form
• Prolonged APTT and low Factor IX
• Rx- 100u/k iv OD , to raise levels to 100%
• Avoid lumbar punctures, IM injections

20. Thrombocytopenia
• Less than 150,000/uL
• Incidence in newborns: 1-5%
• Incidence in NICU – 15-30%
• In VLBW and preterms – 50%
• Causes of thrombocytopenia in newborn:
Neonatal megakaryocytes are smaller
Inadequate production of thrombopoietin

21. Baby Platelet

22. Causes of thrombocytopenia
• Immune-mediated
• Associated with infection - Bacterial or Non-
bacterial
• Drug-Related
• Increased peripheral consumption of platelets –
Disseminated Intravascular
Coagulation, Necrotizing
enterocolitis, hypersplenism
• Genetic and Congenital Anomalies
• Miscellaneous – asphyxia, IUGR, PIH, GDM

23. Early thrombocytopenia
• Placental insufficiency (PIH, IUGR,DM)
• NAITP
• Birth asphyxia
• Perinatal infection
• Maternal autoimmune causes( ITP, SLE)
• Congenital infection
• Inherited – TAR, Wiskott- Aldrich

24. Late Thrombocytopenia
• Late onset sepsis and NEC
• Congenital infection
• Maternal ITP, SLE
• Congenital / Inherited conditions

25. Infection
• Most common cause of thrombocytopenia
in infants
• LOS > EOS
• 50% of babies have platelets < 1 lac/cmm
• 65%, and 47% - sensitivity and specificity
for sepsis
• Viral infections ( intrauterine) cause
severe thrombocytopenia.

26. Immune Thrombocytopenia
• Neonatal allo-immune thrombocytopenia
(NAIT)
• Incidental thrombocytopenia of
pregnancy or Gestational
thrombocytopenia
• Autoimmune thrombocytopenic purpura

27. Neonatal allo-immune
thrombocytopenia (NAIT )
• Incompatibility between mother and baby
• Similar to Rh disease
• Antibodies against HPA – 1 (most common)
• In utero bleed can occur
• Manifests with first pregnancy in 50%
• Postnatal : petechiae, purpura
ICH in 10% with sequelae

28. NAIT
• Management – fetal blood sampling and
platelet transfusion or maternal IVIG
• If previous sibling had a significant bleed
• Caesarian section
• In newborn – maternal platelets or HPA
compatible platelets
• IVIG 1gm/k for 2 days or 0.5g/k for 4 days

29. Autoimmune Thrombocytopenia
• Maternal ITP or SLE
• Transplacental transfer of autoantibodies
• Bleeding manifestations are less severe
• ICH occurs in less than 1%
• Platelets at birth, and day 2
• If less than 30,000/cmm – to give IVIG
• Platelet transfusion is not useful

30. Congenital causes
• TAR , Fanconis anemia,
• Congenital amegakaryocytic anemia
• Trisomy 21, 18,13
• Wiskott Aldrich syndrome
• Noonan’s and Apert’s Syndromes

31. TAR (Thrombocytopenia & Absent
Radii)
• Congenital
• Findings
– Thrombocytopenia
– Absent radii bilaterally
– Small shoulders
– Abnormal knees
– Malabsorption
• History
– Platelets stabilize
– ? Leukemia

32. PT and APTT
• PT: measures extrinsic pathway
• VII, X, II, V
• Normal range : preterm:13s(10.6s-16.2s)
term : 13s(10.1-15.9s)
• APTT: Measures intrinsic pathway
• VIII, IX,XI,XII, X,II, V
• Uses a contact activator like kaolin , silica
• Normal values: Term-42.9s(31s-54s)
Preterm – 53.6s( 27.5 – 79s)

33. Thrombin time
• Measures final step of clotting cascade
• Normal values in newborn
• Prolonged in
hypofibrinogenemia, dysfibrinogenemia,
heparin and FDP
• Reptilase time: uses a snake venom
• Not sensitive to heparin

34. Approach in healthy baby
• Plt PT PTT Diagnosis
• ↓ N N ITP , marrow
aplasia
• N ↑ ↑ VKDB
• N N ↑ Clotting defects
• N N N Trauma, XIII
platelet function

35. Approach in sick neonates
• Plt PT PTT Diagnosis
• ↓ ↑ ↑ DIC
• ↓ N N Sepsis, NEC,RVT
• N ↑ ↑ Liver disease
• N N N
Acidosis, hypoxia

36. Bleeding infant
Screening tests
PT, APTT,TT,PLT
BT , Fg, PFA
All tests normal All abnormal
XIII, alpha2- AP APTT prolonged PT prolonged DIC, Liver failure,
PAI, vWFl VIII,IX,XI,XII,vWF VKDB, Warfarin Severe VKDB
hypofg

37. Thank you
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Medical Post [ www.themedicalpost.net ]